Failure to Update Advance Directive for Hospice Resident
Penalty
Summary
The facility failed to ensure that a resident's right to request or refuse medical treatments was accurately reflected in the resident's record. This deficiency was identified for a resident who was admitted to the facility with a diagnosis of dementia and later placed on hospice care. Despite the change in care status, the resident's advance directive remained as full code, indicating a lack of proper documentation and discussion regarding the resident's end-of-life care preferences. An interview with the Unit Manager confirmed that the Physician Orders for Life-Sustaining Treatment (POLST) should have been discussed with the resident and/or their responsible party when the resident was placed on hospice care. However, this discussion did not occur, leading to a discrepancy between the resident's care plan and their documented advance directives. This oversight highlights a failure in the facility's process to ensure that residents' treatment preferences are accurately documented and respected.
Plan Of Correction
Step 1 Advance Directive for resident R96 reviewed with Responsible party: POLST updated to reflect updated Code status. Step 2 All Hospice residents POLST to be audited to ensure that a resident's right to request or refuse medical treatments were accurately reflected in the resident's record. Step 3 Social Services/nursing management will be educated to ensure that a resident's right to request or refuse medical treatments were accurately reflected in the resident's record. Step 4 Admin/Designee will conduct weekly audits x 4, monthly x2. Findings will be reviewed during QAPI meeting.
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